Feeding Behaviors

Background

Low birth weight infants are at increased risk for developing feeding behavior problems. Disturbances in the feeding relationship, consequences of diseases of prematurity that lead to feeding problems, and strong family concerns about feeding and growth can increase the risk. Once a problem feeding behavior has developed, it may require referral to a feeding team or behavioral specialist. It is clear that anticipatory guidance and close monitoring of the feeding situation is warranted.

Preventative Guidance

Here are some key concepts about feeding behaviors that may be of use to caregivers as they nourish their infants in the first years of life:

Sensitive Periods

There are indications that there are developmental periods when infants are ready to accept advances in taste, texture, and feeding methods. If these "sensitive periods" are missed and the corresponding feeding experience is not provided, it may be difficult for feeding development to progress normally. This issue is especially important for infants who are fed for prolonged periods of time with nasogastric or gastrostomy feedings. If these children are to transition to oral feedings it is vitally important that some kind of ongoing oral therapy be maintained. This usually requires a referral to an infant feeding specialist such as an occupational therapist, physical therapist, or speech therapist.

Division of Responsibility

Ellyn Satter (Satter, 1990) gives us the concept of the role of the infant and the role of the caregiver in feeding. In short, the role of the caregiver is to provide safe, nutritious and adequate food in a pleasant and appropriate environment. The role of the infant or child is to ingest appropriate quantities of food. This concept is especially difficult for parents with children at high risk to embrace, but the reality is that a child cannot be forced to eat, long-term. If a family feels that their baby will not grow unless they "make" their infant ingest a certain amount at each feeding, then other interventions should be explored. These can include altering the nutrient composition of the feeding (see Concentrating Formula), changing the timing of feedings, using tube feedings, and further investigations to rule out a physiological basis for feeding problems (see Feeding Assessment, GER, Aspiration).

Neophobia

Neophobia, or the fear of new tastes and textures, is common among infants and young children. In general, if parents accept this reluctance to try new foods and offer children repeated opportunities to consume food in a comfortable, non-coercive, matter-of-fact way, children will grow to accept variety in the diet.

Picky Eating

There appears to be some association between a very limited and bland diet in the first months of life and multiple food refusals and fussiness about foods later in childhood. Gradual, non-coercive, developmentally appropriate exposure to a wide variety of flavorful foods appears to be sound advice.

Force Feeding

Force feeding is never an effective long-term method for increasing dietary intake. However, parents have been known to resort to force feeding tactics when they feel that they have no alternatives. Health providers need to be especially thoughtful when providing advice about recommended intake and goals for growth so that they don't provoke a force feeding response.

Coaxing

Continually offering a food after it has been refused or engaging in elaborate games to encourage feeding is seldom a successful method of ensuring appropriate dietary intake in the long run.

Food as Reward

Studies of the use of rewards and food bring us the following findings:

Offering a reward for consumption of a food tends to make that food a less favored food.

Offering any food as a reward for good behavior tends to make that food more highly valued by children.

A reasonable conclusion might be that rewards and bribes around issues of food are ultimately not in the interest of developing long-term healthy attitudes toward food.

Interventions

Infants and children who have significant growth or feeding problems and families who have developed serious problems over eating issues will need referrals to specialists for further evaluation and treatment.

Infants and children with mild eating problems can often achieve more desirable patterns by following these suggestions:

Early Infancy

Breastmilk or formula feedings should be offered at 2- to 3-hour intervals, progressing to 3- to 4-hour intervals as the infant matures. Bottles or breast should be offered in response to hunger signals. The infant needs to be reassured that his hunger will be satisfied with food. On the other hand, parents may need to be taught to recognize satiety signals, so that they don't override the infant's cues.

Introduction of Foods

New foods should be introduced in a friendly, non-coercive way. Food refusal should be accepted. New foods should be offered several times, without comment. Spitting out food or throwing of food should be gently and firmly ignored.

Meal and Snack Times for Older Infants

Several daily meals and snacks should be scheduled at predictable intervals. If the infant chooses not to eat at a particular meal or snack, food should not be offered again until the next scheduled eating episode. Meals or snacks should be planned close enough together so that the infant doesn't become overwhelmed with sensations of hunger and lose the ability to control his state. Eating with other family members or young children is often a good way to quietly encourage older infants to expand the repertoire of accepted foods.

Behavioral Therapy

Basic behavioral therapy concepts can sometimes be applied successfully to feeding behavioral problems in the home. These should be planned out with all caregivers in advance and may include:

Positive reinforcement: rewarding a child with praise or non-food reward for targeted behaviors such as sitting calmly at the table for a reasonable period of time.